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From Uruguay, a Model for Making Abortion Safer

With the announcement in April that the Zika virus spreading across Latin America can cause microcephaly in the womb, leaders across the region have come under increased pressure to relax some of the world’s most restrictive laws against abortion.

Only two countries in Latin America have made abortion legal and widely available. Cuba was the first, in 1979; Uruguay the second, in 2012. But it’s the experience of the latter, one of the most democratic countries in Latin America, that offers a lesson in reform — or at least a picture of what is possible.

It started 10 years before the law was passed, with a medical protocol called the “Uruguay Model.” Described by its architects as an “intermediate step” toward allowing abortion, the protocol was designed to make safer the many abortions then being carried out clandestinely.

Indeed, by the late 1990s, unsafe abortions were a leading cause of maternal mortality in Uruguay, accounting for nearly 30 percent of maternal deaths. Nowhere was the problem more pronounced than at the Pereira Rossell Hospital, Uruguay’s main public maternity hospital, which serves a primarily low-income population in the capital, Montevideo. There, nearly half of all maternal deaths were because of unsafe abortions, and in 2001 a group of gynecologists, psychologists, midwives and social workers decided to act.

“The situation was dramatic,” recalls Dr. Leonel Briozzo, Uruguay’s vice minister of public health. Then an adjunct professor at the University of the Republic, Briozzo led the group, called “Iniciativas Sanitarias,” in a pilot program at Pereira Rossell with one aim: to provide women contemplating an abortion with judgment-free, factually accurate information on, among other things, the use of medicines to terminate a pregnancy.

As in other countries where abortion was criminalized, women in Uruguay had turned to the drug misoprostol (Cytotec), which was originally developed as an anti-ulcer therapy. When Cytotec arrived on the market in 1985, the drug’s maker, Searle, hoped it would lead a “product flow renaissance” — a grand plan to revitalize the company’s flailing pharmaceutical business under its president at the time and chief executive officer, Donald Rumsfeld, who had been President Gerald Ford’s secretary of defense and would later return to that position under President George W. Bush.

Little did Searle foresee that, to women with only limited control over their reproductive lives, the warning on the label — “Cytotec should not be taken by pregnant women” — would prove to be better marketing than any ad campaign. It hinted at a chance worth taking, and when it was found to be safer and more effective than other back-alley procedures, the pill’s popularity exploded.

In Cytotec, millions of women suddenly had access to an inexpensive, over-the-counter option for privately terminating a pregnancy and making it look like a miscarriage. Rumsfeld’s company had inadvertently armed the poor and disenfranchised with a powerful new tool — the kind of technology that could cause a revolution.

Governments responded by limiting sales of the drug to hospitals or pharmacies registered with local authorities. Some states in Brazil banned misoprostol entirely. And while women could (and did) continue to obtain misoprostol on the black market, studies suggest that they used it with little knowledge of proper dosing or routes of administration, side effects or follow-up care. Some reported confusing misoprostol with other pills, like emergency and oral contraceptives.

“Misoprostol use in the clandestine practice of abortion has largely developed on a trial and error basis,” Joanna N. Erdman, assistant director and MacBain Chair in Health Law and Policy at Schulich School of Law, Dalhousie University, wrote in a 2011 article in the Harvard Journal of Law and Gender. The question, she added, was “how to reach women with safer-use information in restrictive legal environments.”

The Uruguay Model offered a way forward.

Inspired by needle exchange programs aimed at preventing the spread of H.I.V. through injection drug use, Briozzo and his Uruguayan colleagues took a so-called harm reduction approach to the problem, framing abortion as, first and foremost, a public health concern. While acknowledging the penal code’s prohibition of abortion as a crime in their country (with exceptions in the case of rape and incest and to preserve the health of the woman), they posited that abortion has a “before” and an “after,” and that, during these periods, health care providers were obliged to intervene.

At a “before visit,” a physician would confirm a pregnancy and its gestational age, identify any pathological conditions, and determine whether the woman qualified for a lawful abortion. If she did, abortion services would be rendered upon request. If not, the physician would provide the woman with an evidence-based overview of different methods of clandestine abortion; the risks associated with each method and their legality; alternatives to abortion, and available social support should the woman decide to continue the pregnancy.

Though the physician would explain how to correctly use misoprostol, he or she would provide no information on how or where to obtain the drug, because doing so was against the law. “It was not advice,” says Erdman. “It was not prescribing or promoting,” and it was this, she says, that allowed the Uruguay Model to operate within the law.

In a 2006 paper on the pilot program, Briozzo and colleagues described the “before visit” as an “opportunity for women to be seen as citizens, with rights, who should be provided with information that guarantees that they will be in a better position to take the best decisions, according to their own situations, environment and values.”

All women who attended the “before visit” were encouraged to come in for an “after visit,” for either prenatal or post-abortion care, depending on what they chose to do. For those who had chosen to have an abortion, the physician would “with absolute confidentiality” confirm complete termination of the pregnancy and address any complications. Uterine aspiration would be performed on women with an incomplete abortion. And all women would be offered contraception.

Out of 675 women who attended the “before visit” between March 2004 and June 2005, 495 returned for the “after visit.” Of the 439 women for whom there was information, almost 90 percent had decided to terminate their pregnancies, all of them by using misoprostol. (The rest had chosen to continue the pregnancy, had not been pregnant in the first place, had miscarried, or had met the requirement for a lawful abortion in the hospital.)

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The results were striking: Among women who participated in the program, there were no maternal deaths or severe complications because of abortion. Nor were there any cases of post-abortion sepsis, which had been a leading cause of death from unsafe abortion, at an average of 10 cases per year, at Pereira Rossell.

Harder to quantify, though perhaps more important, was the extent to which the program altered public perceptions. Before it began, Briozzo said in a telephone interview, abortion had been written about only “in the crime section of the newspaper.” But afterward, “the articles were about health and human rights.” With harm reduction, “you make it possible to change how people think about the problem,” he said. “The potential of this model is the potential to change public policy in the country.”

Indeed, though it would be another eight years before Uruguay legalized abortion, the government enacted a regulation to expand the model to all public sector facilities — a tacit recognition that the right to health, as defined under international humanitarian law, “includes the right to seek, receive, and impart information” and, moreover, that this right obligates the state to “refrain from limiting access to” or “withholding or intentionally misrepresenting health-related information.”

Over the next several years, Iniciativas Sanitarias worked with international organizations to replicate the Uruguay Model in nine other countries — all of them larger, poorer and more socially conservative than Uruguay. In none, as of yet, has the model been signed into law or scaled up to the national level, but advocates say it has had a clear impact on unsafe abortion in many of the communities where it was piloted. It has also emboldened providers in those places to speak out publicly, the advocates say.

According to Giselle Carino, regional director of the International Planned Parenthood Federation for the Western Hemisphere, which has supported the Uruguay Model’s expansion, the best example of that may be what happened in Uganda. Several years ago, Carino and her colleagues brought Charles Kiggundu, then president of Uganda’s association of gynecologists and obstetricians, to Montevideo, where he met with Briozzo and saw the model in action. “He’s very well respected in Uganda, and he was frustrated that so many women there were dying of unsafe abortion,” recalls Carino.

After returning home, Kiggundu implemented the model at Mulago Hospital in the capital, Kampala, and took a public stand on the issue — no small thing in a country as socially conservative as Uganda, home to a vehement anti-gay movement. “The country spends 7.5 billion shillings annually treating complications from unsafely performed abortions,” Kiggundu told Ugandan journalists last July. Yet, he added, “when we say sex education, you say no. When we say contraceptives, you say no. When we say safe abortions, you say no. So what do you want?”

Months later, health officials in neighboring Tanzania followed suit, implementing the Uruguay Model as a research study at one public health center in the capital, Dar es Salaam. Carino points out that in Tanzania, as in much of Zika-affected Latin America, abortion is permitted only when the pregnancy endangers the life or health of the woman.

“We think the Uruguay Model can open up possibilities for women where Zika is a threat — in Brazil, in Central America.” After all, she says, it isn’t that ministries of health aren’t concerned about unsafe abortion, which, according to the World Health Organization, accounts for at least 10 percent of maternal deaths in Latin America and the Caribbean and imposes a heavy cost on health systems. But given existing legal conditions, “they’re limited in their ability to address it.” The model provides them, she says, with the means to take action immediately and without engaging the law.

Briozzo notes that in addition to the tragedy of maternal mortality itself, the death of a mother significantly reduces the likelihood of her children’s survival. “So, as we see it, we are the ‘pro-life movement,’ ” he says. “In all of Latin America, it is possible to take this harm-reduction approach, to provide access to information with neutrality, with confidentiality, and with humanity. This is the woman’s right.”